neurosurgery!

All afternoon we were getting one consult after another. The resident eventually gave up on his pager, and just answered every number with, “What’s this consult’s name and medical record number? Thanks, we’ll get there.” All of this activity finally produced, between the ER and the ICU, both a subdural and an epidural hematoma urgently needing surgery.

Around 6pm we started setting up for the subdural. As I have mentioned, whether because of my luck, or lack of initiative, or poor planning, or some other factor, I had a fairly uneventful and therefore less educational surgery experience in medical school. I had scarcely, until this rotation, seen a patient *with* a subdural, let alone seen an evacuation of one. I am now wildly in love with neurosurgery in general, and these guys in particular, because they apparently take the old surgical adage, “see one, do one, teach one,” a step farther, and skip the “see one” part. The chief handed me the scalpel and said, “Get down to the skull.” By this time I’ve learned enough not to *say* anything surprised, even if I can’t help my face. He had me open the skull, and even the dura itself. I could not believe that he was letting me hold a scalpel a millimeter away from the brain surface, but if he was nervous he managed to conceal it pretty well. The attending didn’t do much at all. He just stood and looked over our shoulders, and agreed with the chief’s ideas.

Being after hours, the OR had opened up another room, and we were able to start the next case as soon as the first patient was safely tidied back to the ICU. (Another great thing about emergency cases: no one dawdles about turnover.) This was a younger patient with a recurrent epidural in the space that had been evacuated a few days before. There was no cutting for this one, just lots of irrigation and careful removal of the blood, which was clotted all over the brain surface. (It had gotten under the dura, too.) I got to close half of the large incision, which meant a lot of stitches tied very tightly. After not being in the OR for nearly two months, I was very happy to find my stitches and knots coming out both neat and tight. (The chief doesn’t have the bad effect on my hands that some of the other residents have.)

I didn’t leave the hospital till 11pm; but who needs to sleep, when they can do surgery? After going for so long hardly seeing the OR, and not scrubbing in, I was starting to wonder about my choice of specialty. I wasn’t as miserable as I had expected to be, stuck on the floors. Last night was great. They let me do surgery (neurosurgery!),
and I realized that although I’m not unhappy with doing paperwork in the ICU or on the floors, there’s a big possibility beyond “not unhappy.” I felt ready to stay up all night (the chief, poor guy, still had to, as the ER hadn’t stopped producing people with back pain).

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This morning the chief decided that I’m now competent to handle the call pager. Idiot that I am, I was thrilled at being given such responsibility. One hour and a dozen stat pages later, I wasn’t thrilled any more. “Patient is unresponsive, come see her now.” “Patient would like to discuss completely changing the plan for his surgery that’s scheduled in two hours, come talk to the family.” “Is this patient stable enough to go to the OR for major surgery tomorrow?” Or better yet, “The patient with the PE is unresponsive,” and “your post-op patient is tachypneic, tachycardic, febrile, hypertensive, and has low sats; and his ICP is high.” [intracranial pressure; supposed to stay low] But I learned a lot about emergencies on the neurosurgery floor, and how to handle a dozen urgent items at the same time. If someone doesn’t stop me, I have the feeling I’m going to volunteer to hold the pager tomorrow.

Unfortunately, there’s an adrenaline surge that comes from scrubbing in the OR that somehow doesn’t last twelve hours later when you’re stuck in the ER. Someone insisted on giving us a lecture this afternoon, and I fell asleep in a group of four people looking directly at the lecturer. Very bad form, Alice. I kept myself going by contemplating the fact that in a few years I’m going to be on a schedule like this regularly. The chiefs can operate all night, and still have all their responsibilities during the day. There’s no one to cover for them. But I’m looking forward to when I’ll be keeping long hours in the OR all the time, not dancing around on the outside.